Gastrointestal Unit, Division of Gastroenterology, Groote Schuur Hospital and University of Cape Town

Introduction. Intravenous
(IV) iron sucrose (Venofer®) therapy has merit in the management of
iron deficiency anaemia in 2 categories of gastrointestinal (GI)
patients: those with inflammatory bowel disease (IBD) and those with
obscure or recurrent GI bleeds. We wished to audit the effectiveness of
this practice in our GI patients.

Methods and materials. This
was a retrospective descriptive study of 67 iron-deficiency anaemia
patients seen at the GI clinic who received IV iron therapy as day
cases. Over a 6-month period results were obtained of their full blood
counts and iron studies (n=49) at baseline and post IV iron (Venofer®). Those that received a blood transfusion were excluded.

Results. Participants
were predominantly female (69.4%) and 32.6% had IBD. Mean age was
56.2±19.6 years and mean quantity of IV iron given was 885 mg
(±355 mg) (approximately 3 infusions). No adverse effects were
documented. Mean baseline haemoglobin (Hb) was 10.0 g/dl, with no
differences between the IBD and non-IBD groups. However, post-IV
infusion, the mean Hb increased by 1.2 g/dl. Mean baseline iron was
lower in IBD patients (5.89 mmol/l) than in non-IBD patients (7.8
mmol/l). Post-infusion mean iron for the entire cohort was higher by
6.3 units (11.5 in IBD and 14.4 in non-IBD patients).

Conclusion. IV
iron therapy is safe and shows good response in Hb and iron levels in
IBD and non-IBD patients, but has a more pronounced effect on iron
levels in the latter. These data provide a benchmark for comparison
with other therapies in these categories of our GI patient population.

Surgical Gastroenterology Unit, Groote Schuur
Hospital, and Department of Surgery, Faculty of Health Sciences,
University of Cape Town

Background.
Enteral stenting has evolved over the past decade as an alternative to
surgical bypass in the palliation of malignant gastric outlet
obstruction. In particular, it offers a less invasive option in the
management of patients who are often at significant risk for
peri-procedural morbidity and mortality. This single-centre prospective
study evaluated the success of enteral stenting for the relief of
advanced malignant gastroduodenal obstruction.

Methods.
Between January 2006 and April 2012, 127 patients (74 men, 53 women;
mean age 60.1 years) with clinical, radiological and endoscopic gastric
outlet obstruction as a result of irresectable malignancy due to local
extent, regional or distant metastatic disease or patient choice,
underwent endoscopic placement of a self-expanding metal stent (SEMS)
to relieve symptoms.

Results.
The technical success rate of endoscopic SEMS placement was 96%,
allowing patients to be discharged at a mean of 4 days (range 1 - 23)
post stent placement. Fourteen patients (11%) required placement of a
second stent due to either a long distal stricture or early technical
failure (n=8), or as a result of delayed re-obstruction from tumour ingrowth (n=6). Complications included bleeding (n=2), perforation (n=1), early blockage from a food bolus (n=1), stent migration (n=1) and re-obstruction from stent shortening/deformation (n=1). One patient died following failed stent placement with tumour perforation.

Methods.
We analysed a prospective database documenting patients with temporary
placement of retrievable covered SEMS for benign gastroduodenal
pathology. Technical and clinical successes, as well as short- and
long-term complications were evaluated.

Are current ERCP training requirements adequate to ensure competency in interventional endoscopy?

Background.
Endoscopic retrograde cholangiopancreatography (ERCP) is technically
the most difficult endoscopic procedure to master, with higher failure
and complication rates than other endoscopic interventions.
Recommendations for the number of procedures to be performed before
achieving competence range from 35 to 200. Traditionally, an 80% bile
duct cannulation rate on completion of ERCP training is the desired
aim. In an era where the majority of ERCPs performed are therapeutic,
is this still an adequate form of assessment?

Methods.
An ERCP database was retrospectively reviewed to identify all
procedures performed by trainees. Eight surgical and medical
gastroenterology trainees completed their 2-year subspecialty training
between 2006 and 2012 at Groote Schuur Hospital. No trainee had prior
ERCP experience. Each trainee’s initial 120 supervised ERCPs were
retrospectively reviewed, with division into sequential chronological
groups of 30. Comparisons between assisted and unassisted completed
ERCPs within the trainees’ subgroups were made. Completing an
ERCP entailed both deep biliary cannulation and completion of the
required therapeutic intervention of sphincterotomy, stenting or stone
extraction unaided.

Results.
Six trainees showed a definitive trend towards improvement over the 4
quarters, but only 3 had an ERCP completion rate >75% by the final
quarter. The average trainee unaided completion rate after 120 ERCPs
was 67%.

Conclusion.
Due to the complexity of interventional endoscopy, accreditation in
performing ERCPs should include steady progress and successful
completion rates, rather than an evaluation of biliary cannulation
only. A prospective study is needed to redefine the criteria of
competency in interventional ERCPs.

Aetiological discrimination of the causes of biliary obstruction in the presence of gallbladder stones

L Ferndale, S R Thomson

Introduction.
Malignant bile duct obstruction and choledocholithiasis are the most
common aetiologies of biliary obstruction. Trans-abdominal ultrasound
can identify gallstones with a high sensitivity but it is highly
operator-dependent and does not accurately detect bile duct stones. We
assessed the utility of other clinical and biochemical markers in
predicting the actual cause of the biliary obstruction in patients with
gallbladder stones on trans-abdominal ultrasound.

Methods.
We performed a retrospective analysis of prospectively collected
endoscopic retrograde cholangiopancreaticogram (ERCP) data. Data on
patients undergoing ERCP for suspected choledocholithiasis over a
2-year period were reviewed. Data collected included demographics,
presence of comorbidities and laboratory investigations such as liver
and renal function and haematology tests.

Results. A
total of 162 patients were identified; 40 were excluded because of
failed cannulation or a normal cholangiogram. Of the 122 patients
studied, 82 had confirmed bile duct stones (group 1) and 40 had
alternative diagnoses (group 2). Mean patient age in group 1 was 50.7
years v. 58.2 years in group 2 (p<0.05).
The female to male ratio was higher in group 1 than in group 2. Higher
serum bilirubin and liver enzymes and lower albumin levels also
significantly predicted the finding of alternative diagnoses in these
patients.

Conclusion.
Male gender, higher serum bilirubin and liver enzymes, and lower
albumin levels are predictors of an alternative diagnosis to
choledocholithiasis in patients with gallbladder stones. Accurate
identification of the one-third of patients with no ductal stones would
allow appropriate further imaging prior to an appraisal of ERCP need.

SEMS insertion: Fluoroscopy v. pure endoscopy – a cost comparison

M Govender, D Clarke

Greys Hospital and Department of Health, KwaZulu-Natal

Background.
Self-expanding metal stenting (SEMS) is used for palliation of
dysphagia in oesophageal cancer. In most centres it is performed under
fluoroscopic guidance. Limited access to fluoroscopy at our institution
led us to develop a pure endoscopic technique. We undertook a cost
comparison of both approaches.

Patients and methods. We
performed a prospective analysis of patients stented at Greys Hospital
utilising endoscopy alone compared with patients stented at IALCH in
Durban where fluoroscopy is routinely used. We observed and documented
20 procedures at each centre. Average costing was estimated using
protocols from the Revenue department and private practitioners.
Individual cost drivers include use of the fluoroscopy suite, use of
contrast, screening time and overall procedure time.

Results.
The average additional cost of utilising fluoroscopic guidance for SEMS
insertion is approximately R2 065.00 per patient. The average total
procedure time of the pure endoscopic technique was 5 min (range 4 - 11
min) v. 17.5 min (range 5 - 24 min) for routine fluoroscopy. The use of
screening also exposed the operator to an estimated 1.05 mGy of
radiation per procedure.

Conclusion.
In a resource-limited setting with a high burden of inoperable
oesophageal cancer, time and cost are 2 significant variables. This
simple analysis confirms that the pure endoscopic technique of SEMS
insertion is more cost-effective and time-efficient than routine
fluoroscopy.

Objectives.
Variceal bleeding (VB) is the leading cause of death in cirrhotic
patients with portal hypertension and oesophageal varices. This
prospective single-centre study evaluated the efficacy of emergency
endoscopic intervention in the control of acute VB and the prevention
of rebleeding and death during the index hospital admission in a large
cohort of consecutively treated alcoholic cirrhotic patients after the
first variceal bleed.

Methods. From
January 1984 to August 2011, 448 alcoholic cirrhotic patients (349 men,
99 women; median age 50 years) with VB underwent 805 endoscopic
treatments (556 emergency, 249 elective) during their index hospital
admission. Injection sclerotherapy was used to control bleeding until
1990 and subsequently variceal banding was used. Child-Pugh (C-P) class
and score, endoscopic control of initial bleeding, variceal rebleeding
and survival after the first hospital admission were recorded.

Conclusion.
Despite initial endoscopic control of variceal haemorrhage, 17% of
patients (1/6) rebled during the first hospital admission. The survival
rate of 79.2% was influenced by the severity of liver failure, with
most deaths occurring in C-P grade C patients in this study.

Repairing major laparoscopic bile duct injuries: What does it cost?

S Hofmeyr, J E J Krige, P C Bornman

Surgical Gastroenterology Unit, Groote Schuur and
UCT Private Academic Hospital and Department of Surgery, Faculty of
Health Sciences, University of Cape Town

Background.
A major bile duct injury is an infrequent but potentially
life-threatening complication after laparoscopic cholecystectomy. Few
data exist about the financial implications of duct repair. We aimed to
calculate the costs of operative repair in a cohort of patients who
underwent bile duct reconstruction after major ductal injury.

Methods.
A prospective database was reviewed to identify all patients referred
to the University of Cape Town Private Academic Hospital between 2002
and 2011 for assessment and repair of major laparoscopic bile duct
injuries. The detailed clinical records and billing information were
evaluated to determine all costs from admission to discharge. Total
costs for each patient were adjusted for inflation between year of
repair and 2012.

Surgical and Medical Gastroenterology Units,
Groote Schuur Hospital, Departments of Surgery and Medicine, University
of Cape Town Health Sciences Faculty, Cape Town

Background.
Endoscopic therapy is the standard of care in patients with bleeding
peptic ulcer disease. This study was undertaken to determine the
efficacy of injection therapy, using adrenaline/saline solution (ASS)
alone, with regards to the rate of rebleeding, need for surgery and
death.

Methods.
Over a 21-month period, data were prospectively collected regarding
patients presenting to Groote Schuur Hospital with acute peptic ulcer
bleeding and treated with endoscopic therapy. The rate of rebleeding,
surgical or other intervention and mortality were recorded and
analysed. In addition, demographic data, comorbidity, non-steroidal and
aspirin use, length of hospital stay, transfusion requirements,
endoscopic findings, Rockall score and aetiology of bleeding, were
recorded.

Conclusion.
Single-agent endoscopic intervention controlled bleeding in 76% of
patients with acute peptic ulcer bleeding. In those who rebled, second
endoscopic management controlled bleeding in 70%. Surgery or
embolisation was required in 8.8% of patients. Although overall
mortality was 11%, medical comorbidity, rather than acute bleeding,
accounted for 89% of deaths.

Aim.Key
genes involved in metabolic pathways relating to atherogenic
dyslipidaemia, chronic inflammation, hypercoagulation and iron
dysregulation implicated in insulin resistance as a common feature of
NAFLD, were studied to identify a genetic subgroup at increased risk of
cardiovascular mortality compared with controls.

Methods.
A total of 178 patients diagnosed with NAFLD and 75 controls were
studied using direct sequencing and real-time polymerase chain reaction
(PCR) for mutation detection. The analyses included eight deleterious
low-penetrance mutations in 5 genes: APOE2, APOE4, F2-20210, FV-Leiden,
HFE-C282Y, HFE-H63D, MTHFR-677 and MTHFR-1298. Relevant biochemical
determinations, including ALT level, were performed for all subjects
and compared using appropriate statistical analyses.

Results.
There was no statistically significant difference in genotype
distribution for individual mutations between the NAFLD v. control
subjects. However, in a sub-analysis a significant increase (p=0.04)
in ALT levels was detected in NASH patients found to be heterozygous or
homozygous for the HFE-C282Y and HFE-H63D mutations (n=10), compared with mutation-negative patients (n=34).

Conclusion.
We could not implicate the genes selected from known pathways in
increasing CVD risk in NAFLD patients. However, the close association
between known risk factors for increased CVD morbidity and mortality,
namely raised ALT, NASH and HFE mutations, was confirmed. Subjects with
HFE gene mutations have been found to have an increased CVD risk. The
role of such mutations in increasing CVD risk in NASH patients needs to be investigated.

A pooled analysis of perineal hernia repair after abdominoperineal resection

M Mjoli1, D Sloothaak2, C Buskens2, W Bemelman2, P Tanis2

1. Department of Surgery, Pietermaritzburg Hospital
Complex and University of KwaZulu-Natal, Durban; 2. Department of
Surgery, Academic Medical Centre, University of Amsterdam, The
Netherlands

Aim.
The purpose of this study was to determine the treatment
characteristics and clinical outcomes of patients with perineal hernia
after abdominoperineal resection (APR).

Method.
A systematic literature search revealed 40 individually documented
patients (published between 1944 and 2010). Three patients treated at
the Academic Medical Centre in the Netherlands were also included.
Patient characteristics, repair type and outcome were recorded and a
pooled analysis of the 43 patients was performed.

Results.
Pooled analysis revealed a median time interval of 8 months between APR
and surgical repair of perineal hernia. The surgical approaches were
perineal in 22 patients, open abdominal in 11, open abdominoperineal in
3, laparoscopic in 5 and laparoscopic-perineal in 2 patients. A primary
recurrence was documented in 13 patients and a second recurrence in 3.
The recurrence rate was 5/25 for synthetic or biological mesh, 6/12 for
primary closure and 2/6 for the remaining techniques. Recurrent
perineal hernia was repaired using a synthetic or biological mesh (N=6), primary closure (N=5) or a muscle flap (gluteus or gracilis) (N=4).

Conclusion.
From these limited and biased data based on published case
descriptions, it appears that the recurrence rate of primary perineal
hernia repair after APR is lower with the use of a mesh or other
assisted closure in comparison with primary suture repair.

A review of patients with chronic
hepatitis C treated with pegylated interferon and ribavirin at a
central referral hospital in Durban

V Naidoo, K A Newton

University of KwaZulu-Natal

Introduction and objectives.
Local experience in the treatment of hepatitis C virus (HCV) is
relatively limited, primarily due to fewer HCV patients and limited
resources compared with the developed world. Since 2006 the
Gastroenterology Department at Inkosi Albert Luthuli Central Hospital
(IALCH) has had access to pegylated interferon and ribavirin to treat
suitable HCV patients. We describe our early experience with HCV
treatment in a low-prevalence region, with particular reference to
treatment outcomes.

Methods.
A retrospective audit was performed of HCV patients who received
treatment from the Gastroenterology Department between 2006 and 2011.
Data were obtained from standard data sheets used to aid patient
management during treatment and patient records. Demographics,
genotype, early virological response (EVR) and sustained virological
response (SVR) were recorded. Simple descriptive statistics were used
to analyse data.

Results.
A total of 7 patients received treatment. One patient who had
genotype-1 infection, a high baseline viral load and type 2 diabetes
mellitus, did not achieve an EVR and treatment was stopped after 16
weeks. One patient had genotype-1 infection, 3 had genotype-3, 1 had
genotype-4 and 2 had genotype-5 infection. Five out of the 6 patients
who completed a standard course of treatment achieved SVR (83%). Both
patients with genotype-5 infection were treated for 48 weeks and
achieved SVR.

Conclusion.
Despite the small number of patients treated, it is rewarding to
document that a significant number who completed treatment achieved SVR
which equates to a cure.

Re-activated Wnt signalling is crucial in hepatocellular carcinoma pathogenesis in double-transgenic mice that constitutively over-express HBx and IRS-1 in the liver

M Setshedi

University of Cape Town

Background.
Hepatocellular carcinoma (HCC) is associated Wnt/β-catenin with
aberrant growth factor signalling. Both the insulin/insulin-like growth
factor (IGF) and Wnt/β-catenin have been implicated in the
pathogenesis of HCC. To date there are no therapeutic molecules
targeting this pathway; therefore, identifying the target genes of Wnt
signalling remains critical for understanding β-catenin-mediated
carcinogenesis.

Aim.
The purpose of this work was to characterise the gene expression
patterns of Wnt/β-catenin signalling in a double-transgenic mouse
model of HCC.

Methods. We analysed liver tissue from mice sacrificed at various time points (n=12
per time point) by quantitative real-time polymerase chain reaction
(qRT-PCR) using a PCR array panel. Wildtype mice were used as controls.

Results.
Tumours developed only in male mice generally after 15 - 18 months. The
majority of Wnt ligands, receptors and downstream targets were
upregulated in mice without tumours at early time points. However, some
genes including Wnt-1, -2, -3, -4, -6, -7b, -11 and Fzd-8, -2, -3 and Fzd-b were also upregulated in HCC (occurring at later time points), suggesting re-activation of Wnt signalling in HCC. Specifically Wnt-5b and -7b
were significantly upregulated in mice with tumours, suggesting they
may be key regulators in hepatitis B virus (HBV)-related HCC.

Conclusions. Our study identified several candidate genes of Wnt signalling, particularly Wnt5b and -7b
that are dysregulated and in combination with 1 or more co-factors,
i.e. HBx and/or insulin receptor substrate-1 (IRS-1) are carcinogenic
in mouse HCC. These genes may serve as useful potential therapeutic
targets for the treatment of HCC.

IL28B polymorphisms are not predictive in South African patients infected with hepatitis C genotype 5

Background.
Hepatitis C virus (HCV)-genotype 5 (G5), endemic in southern Africa, is
often neglected in major trials. While single nucleotide polymorphisms
(SNPs) of the interleukin-28B gene (IL28B)
on chromosome 19 have been associated with treatment response in
genotypes 1 - 4, scant data and only in white patients, suggest no
predictive value of IL28B in HCV-G5. No such data exist for South African patients or those of different ethnicities.

Methods.
Genomic DNA was obtained from peripheral blood mononuclear cells
(PBMCs) in a cohort of G5 patients and analysed for the rs12979860 SNP
near IL28B.
Treated patients in the cohort had received peg-interferon-α-2a
and weight-based ribavirin. Genotypes were analysed for their
association with treatment response.

Conclusions. In this albeit modest cohort of treated HCV-G5 patients of different ethnicities, IL28B
polymorphisms did not significantly predict RVR or SVR. This may
reflect that the viral kinetics of HCV-G5 more closely resemble -G2 and
-G3, although a larger study is required to confirm this finding.

Gastrointestinal Unit, Groote Schuur Hospital and University of Cape Town

Background.
Laparoscopic Heller’s myotomy (LHM) and pneumatic balloon
dilatation (PBD) are widely used in the management of achalasia.
Consensus among experts on the superior treatment modality is lacking.

Methods.
Achalasia patients who presented between 1999 and 2007 were assessed
for entry into a randomised controlled trial between LHM and PBD.
Clinical data were collected prospectively, including weight loss,
dysphagia, chest pain, regurgitation, heartburn and dysphagia score.
Due to patient preference, only one-third of patients were randomised
to either therapy. Both randomised and non-randomised patients were
evaluated. The primary outcome of success was defined as relief of
dysphagia without the need for an alternative intervention.
Complication rate was evaluated as a secondary outcome.

Results.
Twenty-nine of the 45 patients (64%) had PBD and 16 (36%) had LHM.
There was no difference between the 2 treatment groups with regards to
baseline characteristics. The median follow-up period was 30 months
(range 1 - 96 months). The success rate in LHM patients was 81% (13/16)
v. 69% (20/29) for PBD. This trend was not significant. None of the
clinical parameters evaluated were predictive of failure risk. The
complication rate was confined to the LHM 11% (5/45) and included 2
perforations in the LHM arm, recognised and treated during the initial
procedure and a peptic stricture.

Conclusion.
Although there is a bias in favour of LHM, the 2 treatment modalities
are comparable in efficacy. Interventions were safe with no mortality.

Methods.
Consecutive patients attending CHBAH hepatitis C clinic between 2007
and April 2012 were considered for enrolment. Demographics, clinical
data, HCV genotype and treatment response were analysed. Patients were
treated with peginterferon-α-2a and ribavirin according to SA
guidelines.

Results.
Fifty-eight patients (30 male, 28 female; mean age 52.4 years) were
enrolled. The majority were blacks (46; 79.3%), followed by Asians (7;
12.1%), and whites (5; 8.6%). The predominant HCV genotype was 5a (26;
44.8%), all occurring in black patients. Among the remaining 32
patients, 11 had genotype 1; 9 had genotype 3 (mostly Asians); 6 had
genotype 4 (3 from the DRC); and 3 patients had 2 genotypes (1b and 4a;
1b and 5a; 1 and 4). Genotyping was not performed in 3 patients.
Thirty-six patients (62.1%) received treatment: 17 achieved sustained
viral response (SVR), 3 were non-responders (all genotype 1 with
compensated cirrhosis), treatment is ongoing in 13, 2 relapsed and
treatment was ceased in 1 due to adverse events. Nineteen patients did
not qualify for treatment (decompensated cirrhosis in 14) and 3 were
lost to follow-up. Twenty-one of the 36 patients developed
side-effects.

Conclusion.
HCV genotype 5 occurred exclusively in black patients. They responded
well to therapy but, if untreated, followed the same natural history.
Treatment was generally well tolerated with the most common side-effect
being bone marrow suppression, which responded to dose adjustments and
supportive therapy.

An unusual cause of upper gastrointestinal bleeding

W Abuelhassan, R Ally

Gastroenterology Department, Chris Hani Baragwanath Academic Hospital

Introduction.
Most of the causes of brisk upper gastrointestinal bleeding can be
diagnosed during oesophagogastroduodenoscopy. However, the diagnostic
dilemma ensues when no cause for the bleeding is readily obvious.

Case presentation.
A 45-year-old female patient with HIV infection (CD4 count of 445
cells/µl) presented to the emergency department with acute
haematemesis. She was pale, haemodynamically stable with 8 g/dl
haemoglobin, had a normal coagulation profile and cholestasis on liver
function tests (LFTs). Urgent endoscopy was performed, which was
normal. During admission, the patient developed malaena and her
haemoglobin dropped to 3.8 g/dl. Repeat endoscopy showed a normal
oesophagus, stomach and duodenal cap. Upon touching the ampulla of
Vater, a jet of blood spurted through the ampulla (haemobilia). Urgent
angiography of the coeliac axis was performed and revealed multiple
aneurysms of the hepatic, left gastric and left gastroduodenal
arteries, which were subsequently embolised. A diagnosis of HIV
vasculopathy was made. The patient remained well with no further
bleeding in the ensuing period and was subsequently discharged with a
referral for initiation of antiretroviral therapy.

Discussion.
Haemobilia is a relatively common under-diagnosed cause of upper
gastrointestinal bleeding with considerable morbidity and mortality.
Angiography can aid in depicting the source of active bleeding.
Aneurysms associated with HIV vasculopathy have been described mainly
in the cerebral and popliteal circulations, with few reports of
mesenteric and portal circulation vasculopathy. Clues to diagnosis
include the presence of multiple aneurysms on angiography in an HIV
patient, and are often associated with deranged LFTs.

Single institution experience with Zollinger-Ellison syndrome: Causes of death and survival pattern

S Alharethi, S R Thomson, P C Bornman

Groote Schuur Hospital, Cape Town

Background.
Mortality in Zollinger-Ellison syndrome (ZES) is not clearly
established. We report a mortality analysis in a tertiary institution
cohort.

Patients and methods. Forty-eight
consecutive ZES patients were managed at Groote Schuur Hospital between
1978 and 2012. Thirty-five males (73%) and 13 females (27%) were
diagnosed at a mean age of 40 years. Forty (83%) patients had sporadic
disease and 8 (17%) had multiple endocrine neoplasia type-1 (MEN-1).

Results.
Nineteen patients with a mean follow-up of 10.4 years died during the
study period; 4 had MEN-1-associated gastrinoma. Nine patients are
still attending follow-up (mean 19.7 years). Twenty patients had
variable follow-up with a mean of 8.5 years. Five deaths were related
to ZES, 2 patients died from duodenal ulcer haemorrhage, 1 from
post-operative septic complications following repeated surgery, 1 from
tumour progression, and 14 deaths were unrelated to ZES.

Conclusion.
ZES is compatible with long-term survival. The majority of deaths are
unrelated to ZES. Death from tumour progression is rare. Patients
undergoing recurrent surgery are at increased risk of
complications-related death.

Patients and methods.
We report a single-institution experience over a 32-year period of 8
patients with MEN-1 identified from 48 patients with Zollinger-Ellison
syndrome. The mean age at diagnosis was 38 years.

Results.
Seven patients presented with ZES or its complications, while 1 patient
presented with hypercalcaemia. The average delay from onset of symptoms
to diagnosis of ZES/MEN-1 was 6.5 years. Prior to diagnosis, 8 patients
had surgery for peptic ulcer complications and 2 had parathyroidectomy.
Prolactin was raised in 8 patients, abnormal pituitary/cella turcica
was seen on computed tomography (CT) in 6 patients and 1 patient had
acromegaly. Five patients underwent post-diagnosis parathyroidectomy
with immediate normalisation of calcium in 4 and repeat surgery
required in 1 patient. After diagnosis, 3 patients had no further
surgical intervention for ZES. One patient had total gastrectomy. One
had distal pancreatectomy and total gastrectomy. The remaining 3
patients each had 2 debulking procedures for a variety of pancreatic
neuroendocrine tumours. No clinical or biochemical cure was achieved in
this cohort. The median survival time was 18 years. There were 4
patient deaths, and 3 patients were lost to follow-up. One patient is
alive and well.

Conclusion.
This study confirmed that surgery does not cure MEN-1-associated ZES.
Screening for MEN-1 is required in all ZES patients even in the absence
of family history. Long-term survival is the rule; hence, follow-up to
detect metachronous neuroendocrine tumours is important.

Background and aims. The
estimated prevalence of coeliac disease (CD) in patients with type 1
diabetes mellitus (T1DM) is 5%. CD and T1DM, both multifactorial
diseases, are strongly clustered in families. In both, human leukocyte
antigen (HLA) class II molecules HLA-DQ2.5 (DQB1*02-DQA1-05) and DQ8
(DQB1*0302 - DQA1*0301) are key genetic risk factors. We aimed to
investigate HLA-DQ distributions in patients diagnosed with both T1DM
and CD. Associations were examined between HLA-DQ and age of clinical
onset and autoimmune comorbidity.

Material and methods.
Patients with T1DM and concomitant CD were recruited from 33 hospitals
in the Netherlands. We retrospectively collected data at T1DM and CD
diagnosis, and regarding comorbidity of autoimmune diseases. T1DM
diagnosis was defined as an absolute requirement of insulin, while CD
diagnosis was based on international criteria (European Society for
Paediatric Gastroenterology, Hepatology and Nutrition). Genomic DNA
obtained from peripheral blood was used for typing of HLA-DQA1* and
DQB1* alleles, performed with a combined single-stranded conformation
polymorphism (SSCP)/ heteroduplex method by semi-automated
electrophoresis and gel-staining. Patients were divided into two
groups, childhood-onset T1DM (before age 20 years) and adult-onset
T1DM, because childhood-onset is strongly associated with HLA
haplotypes.

Results. The
total cohort consisted of 61 patients diagnosed with T1DM and CD (67.2%
female; mean age 39.8±19.8 years; T1DM and CD duration of
22.6±16.8 years and 8.3±10.4 years, respectively). All
patients were unrelated and self-reported Dutch whites. Patients
carried HLA-DQ2.5 in 80.3% (50.8% heterozygous and 29% homozygous).
Only 6/61 (9.8%) patients were diagnosed with CD before T1D; 50% of
them were HLA-DQ2.5 homozygous. In the childhood-onset T1DM group (n=38), mean age of T1DM onset was significantly lower in HLA DQ-8 heterozygotes v. other genotypes (4.9 v. 8.0 years; p=0.04).

Conclusions.
In patients with T1DM and CD, an 80.3% prevalence of carriers of
HLA-DQ2.5 was found. Interestingly, in the childhood-onset T1DM group,
a younger age of T1DM onset is associated with heterozygous HLA-DQ8. No
associations were found between HLA-DQ type and the prevalence of
autoimmune comorbidity or CD onset.

Surgery for giant-giant gastric ulcers – the bedsore of the stomach: A report of 6 recent cases

H Becker

Department of Surgery, School of Medicine, Faculty of Health Sciences, University of Pretoria

Introduction.
Patients with giant gastric ulcers (≥3 cm) are significantly older
and have more aggressive disease, reflected by a higher incidence of
bleeding, anorexia, weight loss and emergency admission (Raju GS et al.,Am J Gastroenterol 1999;94:3478-3486).
These patients need prolonged aggressive treatment, with excellent
compliance. The author wishes to propose a further subgroup of giants
ulcers that are ≥3 cm but also have a deep penetrating base into
adjacent organs (crater), where the base of the crater is an organ,
usually the pancreas, liver or porta hepatic.

Postulate.
These giant-giant (bedsore) ulcers will not heal, but become chronic
and complicated with treatment. A low threshold for early referral to
surgery is necessary. If little improvement is seen after 3 months of
adequate medical treatment, surgery is indicated.

Material and methods.
Six patients underwent emergency operations for uncontrollable
haemorrhage from large penetrating gastric ulcers between December 2011
and May 2012. All patients needed definitive gastric surgery to control
haemorrhaging (subtotal gastrectomy/antrectomy, including the ulcer,
with or without truncal vagotomy).

Conclusion.
Patients with giant penetrating gastric ulcers need early referral for
definitive surgery. A low threshold for referral is imperative.

Surgical Gastroenterology Unit, Groote Schuur
Hospital and Department of Surgery, Faculty of Health Sciences,
University of Cape Town

Background.
Both plastic and self-expanding metal stents (SEMS) have been used to
relieve jaundice in patients with advanced malignant biliary
obstruction. This study compared the clinical efficacy of plastic v.
metal biliary stents.

Materials and methods.
In a prospective randomised controlled trial 37 patients with malignant
common bile duct obstruction not amenable to curative resection were
offered palliative stenting from November 2008 to March 2012 and were
followed-up until death. We compared patient survival and stent patency
rates.

Results. Seventeen
patients received 10 Fr. plastic stents and 20 patients received SEMS.
Mean duration of hospital stay after stenting was 2 days (range 1 - 2).
One patient in each group remained jaundiced despite adequate biliary
drainage. Plastic stents blocked more frequently than SEMS (47.5% v.
10.0%; p=0.015).
In the SEMS group, 3 patients required re-admission to hospital (total
31 days) and median survival was 116 days, compared with 5
re-admissions (total 54 days) and a median survival of 105 days in the
plastic stent group. Preliminary cost analysis showed similar costs per
patient in both groups.

Conclusion.
Plastic 10 Fr. biliary stents block more frequently than SEMS, which
have a better patency rate and are associated with fewer hospital
re-admissions. Metal stents are cost-effective in palliating malignant
biliary obstruction in a public sector hospital.

Autoimmune hepatitis at Chris Hani Baragwanath Academic Hospital

B Bobat, R Ally

Chris Hani Baragwanath Academic Hospital, Johannesburg

Background.
Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease of
any age, evidenced by variable and fluctuating clinical features and
serum auto-antibodies.

Methods.
An audit was performed of 15 AIH cases identified after a review of 243
patients attending the liver clinic at CHBAH between 2009 and 2012.
Demographics, clinical, laboratory and histology data, auto-antibodies,
derived clinical scores and therapy were reviewed.

Conclusions.
AIH at CHBAH has a female predominance and mainly affects young adults;
50% are clinically ill at presentation. ANA testing was a good
indicator of disease, while ASMA and ALKM testing were not; anti-liver
cytosol (ALC) may be a better option. Liver biopsies proved to be
typical. Most patients responded very well to immunosuppressive
therapy.

Background.
A bile leak is an infrequent but potentially serious complication after
biliary surgery. The aim of this study was to assess the effectiveness
of endoscopic management.

Methods.
An endoscopic retrograde cholangiopancreatography (ERCP) database was
retrospectively reviewed to identify all patients with bile leaks after
laparoscopic cholecystectomy.

Results.
One hundred and thirteen patients (92 women, 21 men) of median age 47
years (range 22 - 82) with a bile leak were referred at a median of
18.1 days (range 1 - 226) after surgery. Symptoms included pain (13;
11.5%), abnormal liver function tests (LFTs) (22; 19.5%), bile leak
(25; 22.1%), intra-abdominal collections (45; 39.8%) and sepsis (8;
7%). Twenty-nine patients (25.7%) were found to have a major bile duct
injury without duct continuity, requiring surgery. Forty-four patients
had a cystic duct (CD) leak, 26 had a CD leak and common bile duct
(CBD) stones, and 14 patients had a CBD injury amenable to endoscopic
stenting. In the 70 patients with CD leaks, 24 underwent a
sphincterotomy (including 8 stone extractions), 43 had a sphincterotomy
and stenting (including 18 stone extractions), 1 patient had stenting
only, while 2 with previous sphincterotomies required no further
intervention. Of the 14 patients with CBD injuries treated
endoscopically, 7 had a class D injury, 3 had a class E5 injury, 3 had
a class B injury and 1 had a biliary stricture. The 113 patients
underwent a total of 269 ERCPs (mean 2.4; range 1 - 7).

Conclusions.
Bile leaks after laparoscopic cholecystectomy in 75% of patients were
due to CD leaks (with or without retained stones) or lesser bile duct
injuries; these were amenable to definitive endoscopic therapy.

Inflammatory bowel disease (IBD) in Soweto

Background.
IBD is an integrated group of disorders characterised by recurrent,
destructive inflammation of the gastrointestinal tract. The most common
forms include ulcerative colitis (UC) and Crohn’s disease (CD).
Most studies arise from Western populations; few, if any, describe IBD
in the South African black population.

Aim.
To establish a formal IBD clinic at Chris Hani Baragwanath Academic
Hospital (CHBAH), we assessed the demographics, disease spectrum and
treatment responses in a cohort of CHBAH patients.

Methods.
From January 2011 to March 2012 all patients with a confirmed diagnosis
of IBD on histology, irrespective of original date of diagnosis, were
recruited. Patient files were analysed and data collected.

Results.Thirty-five
patients, including 20 females, were recruited; 88.6% were black, 8.6%
were white and 2.8% were Asian. IBD subtypes included UC (91.4%) and CD
(8.6%). In the latter, only 2 patients were black and 1 was white. In
the UC group, left-sided colitis comprised 47%, pancolitis 44% and
distal colitis 9%. The most common extra intestinal manifestation was
primary sclerosing cholangitis, followed by arthropathy. No patient had
skin or eye involvement. The mainstay of treatment included
salazopyrin, corticosteroids and azathioprine. No patient was on
6-mercaptopurine (6MP) or biologicals. Three patients were defined as
having steroid-dependent CD (too small for further analysis).

Conclusion.
IBD is common in our Soweto community. A high index of suspicion is
needed for the diagnosis of more cases. Specialised clinics and
registries are needed to improve patient outcome and quality of life.

Case summary: The neuroendocrine tumour effect

History.
We report a case of a 53-year-old male patient who presented with
syncope and haematemesis in a second presentation after almost 1 year.
Gastroduodenoscopy 1 year preceding was reported as normal. No other
previous background history was notable.

Examination and findings.
The patient appeared well, apart from postural hypotension and sinus
tachycardia. His haemoglobin was 14.5 g/dl and coagulation profile was
normal. At 22h00 he complicated and had massive haematemesis
necessitating intensive care unit (ICU) admission. The patient was
resuscitated and received a proton pump inhibitor (PPI) infusion.
Emergency endoscopy revealed blood in the stomach, making visualisation
difficult. Endoscopic haemostasis was achieved with epinephrine
injections blindly at the site thought to be bleeding. Repeat endoscopy
revealed a reddish mass lesion along the lesser curvature of the
stomach, with active bleeding, resulting in emergency surgery. At
surgery, a well-delineated mass was found with histology consistent
with a well-differentiated neuroendocrine tumour (NET) that extends
into the muscularis. Gastrin and chromogranin A were normal. A
diagnosis of a type 3 NET was made. Octreoscan showed no evidence of
distant disease. He was referred to oncology and completed
chemotherapy. He has had an excellent outcome so far.

Discussion.
Although rare, NET must be considered as a cause of haematemesis.
Various diagnostic tools including specific urine and serum markers may
help to identify a specific tumour type Tumour localisation and
metastasis is performed via endoscopy, radiological imaging and
somastatin receptor scintigraphy. Treatment modalities include surgery,
somastatin analogues, chemotherapy and radiotherapy.

HIV/AIDS cholangiopathy, biochemical, histological and cholangiographic features in a South African cohort

Methods.
In a pilot study, data were collected from our Liver Clinic. HIV
patients with elevated cholestatic enzymes (>2 times the upper limit
of normal for alkaline phosphatase (ALP) and gamma glutamyl transferase
(GGT)), but without viral, drug, autoimmune hepatitis or diabetes or
high level of alcohol consumption were recruited. All patients
underwent an ultrasound to exclude obstructive aetiologies. Endoscopic
retrograde/magnetic resonance cholangiopancreatography (ERCP)/(MRCP)
and liver biopsy was performed in selected cases.

Results.From December 2011 to March 2012, 19 patients (including 10 men) were recruited. Abdominal pain (n=12)
was the most common manifestation; the remaining patients were
asymptomatic. Mean ALP and GGT were 720 U/l and 1 127 U/l,
respectively. The mean CD4 lymphocyte count was 120 cells/mm3 .
Only 3 patients were on highly active antiretroviral therapy (HAART) at
presentation. Ultrasonography was abnormal in only 3 patients (dilated
common bile duct); 63% underwent ERCP, with the major finding being
paucity of the peripheral bile ducts (58%). The most common finding on
liver histology was granulomatous hepatitis (32%). Mycobacterium was the most common opportunistic infection.

Conclusion.
HIV-associated cholangiopathy is not uncommon in the SA HIV population.
ERCP is an important diagnostic and therapeutic modality. Liver
histology is a powerful diagnostic tool for opportunistic infections.

Clinical, laboratory and outcome data of hepatocellular carcinoma in Mozambique

Background.
Hepatocellular carcinoma (HCC) is a lethal cancer and represents the
fifth most common malignancy in the world. Data on clinical and
laboratory characteristics and prevalence of hepatitis virus infection
among HCC patients in Mozambique are scarce. We aimed to investigate
these parameters in HCC patients attending Maputo Central Hospital
(Hospital Central de Maputo) (HCM).

Methods.
Between March 2011 and April 2012, 105 patients with HCC attending HCM,
were enrolled and screened for hepatitis B virus (HBV), hepatitis C
virus (HCV) and HIV. Alpha-fetoprotein levels, abdominal ultrasound and
fine needle aspiration (FNA) for cytology were performed routinely.
Clinical and demographic data were collected using a standard
questionnaire.

Results.
HCC was most frequent in men (72.4%) and mean patient age was
49.7±15.7 years. Lower educational level, history of smoking and
alcohol intake were found in 69%, 5.7% and 58% of patients,
respectively. The prevalence of HBV, HCV and HIV infection was 52.9%,
4.9% and 11.9%, respectively. HBV/HIV co-infection was found in 9% of
patients. No patient was co-infected with HBV/HCV or HCV/HIV.
Alpha-fetoprotein was >400 UI in 62.7% of patients. Multinodular
presentation in the liver was detected by ultrasound in 80%. Mean
survival was 66.5±6.7 days.

Conclusions.
Overall, our data demonstrated that chronic HBV infection is highly
prevalent in Mozambican HCC patients, suggesting that HBV represents
the major cause of HCC. The poor survival rate may reflect the advanced
stage of tumours at the time of diagnosis.

Colorectal cancer in Ugandan patients: A morphological study

Introduction.
Colorectal cancer (CRC) is uncommon in Africa. Inherited cancers may
account for a greater portion of the disease burden in low- v.
high-incidence areas. CRC-related demographics and histological
features and the incidence of hereditary nonpolyposis colorectal cancer (HNPCC) in African populations are largely unknown.

Aim. To assess the demographic and morphological features of CRC patients from hospitals in Mulago and Mbarara, Uganda.

Results.
The median CRC patient age was 55 years (range 20 - 89) at diagnosis;
30.6% and 6.9% were aged <50 and <30 years, respectively. Tumours
were mostly (94.9%) located in the left side of the colon. Mucinous
adenocarcinoma was significantly more common in patients aged <50
years. Based on the histological and demographic features, 22/81
(27.3%) patients met at least 1 criterion of the revised Bethesda
Guidelines for MSI testing.

Conclusions.
Histological and demographic features suggestive of HNPCC were
identified in 27.3% of patients. These features appear to be quite
different from published data from First-World countries. The lack of
endoscopic equipment in Uganda may account for the majority of cancers
being left-sided.

MRCP and ERCP demonstration of biliary tract disease

M Lagaud, Z Ghoor, O Mzileni, A Elnagar

Dr George Mukhari Hospital, Department of Health, Gauteng

Introduction. Hepatobiliary
diseases are often effectively diagnosed by abnormal liver biochemical
tests and ultrasonography. However, there are also unusual cases that
may require additional diagnostic procedures such as magnetic resonance
cholangiopancreatography (MRCP) and endoscopic retrograde
cholangiopancreatography (ERCP). Clinical features often do not present
the true extent of the disease, especially in patients with
AIDS-related cholangiopathy. This presentation reports a case of
biliary disease diagnosed and managed by MRCP and ERCP.

Discussion.
MRCP and ERCP performed equally well. MRCP should be used to screen
AIDS patients, irrespective of the pattern of the liver enzymes
abnormalities. MRCP also helps to select appropriate patients for ERCP,
which will be required to obtain tissue samples for microbiological
studies and for sphincterotomy (if needed).

Repeat endoscopic rapid urease test as a surrogate marker for the success of Helicobacter pylori eradication

D Levin, P Williams, S R Thomson

PAWC and Groote Schuur Hospital, Cape Town

Background. Amoxil and metronidazole are first-line antimicrobial eradication therapy for Helicobacter pylori infection
at Groote Schuur Hospital. Metronidazole resistance is purported to be
high. There are no local data assessing the efficacy of this strategy.

Methods. We evaluated the efficacy of antimicrobial therapy in patients with H. pylori
infection, in patients with a positive rapid urease test (RUT) at
initial endoscopy and who underwent a repeat endoscopy and RUT. Data
analysed included those from a prospective endoscopy database that were
merged with the antibiotic regimen dispensed from our pharmacy
database. A positive RUT at index and a negative RUT at repeat
endoscopy were considered successful eradication.

Results. Over a 48-month period, 270 patients positive for H. pylori
infection at index endoscopy underwent a repeat endoscopy and repeat
RUT; 132 patients had a positive RUT at index, but negative RUT at
repeat endoscopy; H. pylori was considered to be successfully eradicated in 132/270 (49%). One hundred and thirty-eight patients were positive for H. pylori infection
at both index and repeat endoscopy. Seventy-four patients received
antibiotic therapy at the index endoscopy, from our pharmacy.
Sixty-four of 138 (46.4%) patients did not receive treatment from our
pharmacy at index endoscopy. After excluding those who did not receive
therapy, the failure rate for H. pylori eradication was 74/206 (36%).

Conclusions. This selected sample revealed an H. pylori eradication
rate of 36%, far below the standard efficacy rate of <10%. The study
also identified a possible prescription-dispensing problem that may
have contributed to the high eradication failure rate.

A clinicopathological spectrum of anal cancer in Kwazulu-Natal

T E Madiba, X H Ntombela

University of KwaZulu-Natal

Aim. To document our experience with the management of anal cancer presenting to the KwaZulu-Natal teaching hospitals.

Results.
One hundred and thirty patients were included in the study (M:F ratio,
1:1, mean age, 51±14.0 years). Presenting symptoms were anal
mass (41), bleeding (27), ulcer (24), loss of weight and/or appetite
(19), anal pain (18), peri-anal abscess/fistula (16), change in bowel
habit (14), warts (8), and incontinence (6). Mean duration of symptoms
was 15.37±19.41 months. Histology confirmed squamous carcinoma
in 95, adenocarcinoma in 33, melanoma in 1 and neuroendocrine tumour in
1. There were 104 anal margin tumours and 26 anal canal tumours. Ten
patients (8%) had distant metastases at diagnosis. Ten patients (8%)
were eligible for surgery. The remainder were managed non-operatively.
Seventy-nine patients were lost to follow-up and the rest were followed
up for 1 - 69 months (mean 16±17.0 months). Eleven patients have
been confirmed to have died so far.

Conclusion.
Anal cancer affects all population groups with an equal incidence in
both sexes. Squamous carcinoma was 3 times as common as adenocarcinoma.
Anal margin tumours were 5 times as common as anal canal tumours.
Delayed clinical diagnosis leads to poor prognosis.

Metastatic colorectal cancer in KwaZulu-Natal: A 12-year experience

T E Madiba, R Naidoo

University of KwaZulu-Natal

Background. The liver is the most common site of colorectal metastases, followed by the lungs.

Conclusion.
Metastatic colorectal carcinoma accounts for 17% of CRC in
KwaZulu-Natal. The liver is the most common site. The surgical
intervention rate is extremely low in our setting. Patient follow-up
remains a problem. Not surprisingly, there is an appreciable mortality.

Predictors for new bleeding in
patients with higher digestive haemorrhage due to portal hypertension
in Maputo Central Hospital, Mozambique

P Modcoicar, L Cunha, J Arteaga

Service of Gastroenterology, Hospital Central de Maputo, Mozambique

Objective.
Variceal rebleeding frequently develops after acute variceal bleeding
and is the most life-threatening complication in patients with
cirrhosis. We aimed to ascertain the predictive factors of new episodes
of bleeding due to rupture of oesophageal varices (EHV) and first
episodes of bleeding after placement of elastic bandages in patients
suffering from portal hypertension (PHT).

Conclusions.
Irregular follow-up and pancytopenia in both arms, and anaemia in the
second arm, are predictors of new episodes of bleeding in our setting.

A case of collagenous gastritis in an 18-year-old black female from Zambia

I Moola, A Mahomed

Charlotte Maxeke Johannesburg Academic Hospital

Case report.
An 18-year-old black Zambian female residing in Johannesburg presented
with vomiting, fatigue and malaise. Aside from pallor, her physical
examination was normal. Her full blood count showed hypochromic
microcytic anaemia. Her haemoglobin (Hb) was 4.7 g/dl, MCV (mean
corpuscular volume) was 68.8 fl, and white cell count and platelet
counts were normal. Further investigation showed severe iron deficiency
anaemia with 1.1 µmol/l (9.0 - 30.4) serum iron, 2 µg/l (5
- 148) ferritin and 1% percentage saturation. Vitamin B12
and red cell folate levels were normal. Gastroscopy showed an extensive
pangastritis with nodular infiltrate most marked in the fundus and
corpus of the stomach. The nodules were 4 - 8 mm in diameter. No active
bleeding, erosions or ulceration was noted. The duodenum and oesophagus
were normal macroscopically. Biopsy of the affected lesions showed
severe chronic gastritis with severe activity, with evidence of
erosions, focal ulceration and atrophy with focally prominent
submucosal fibrosis. No intestinal metaplasia, dysplasia or malignancy
was noted. Helicobacter pylori infection
was not observed. The differential diagnosis was collagenous gastritis
and auto-immune gastritis. Other differentials were scleroderma and
post-radiation therapy changes. Extensive physical and biochemical
investigation revealed no other abnormalities. Follow-up colonoscopy
showed a normal-looking mucosa with no features of collagenous colitis.
A diagnosis of collagenous gastritis was made. Follow-up gastroscopy
after 1 year of oral 20 mg omeprazole daily showed similar endoscopic
appearance. The iron deficiency was treated with intravenous iron and
the patient’s full blood count normalised. She is currently
asymptomatic.

Outcome of cricopharyngomyotomy and diverticulopexy for Zenker’s diverticulum

P Nel, H van der Walt

Objectives.
To determine the outcomes after long-term follow-up of patients who
underwent Zenker’s diverticulum repair using only
cricopharyngomyotomy with diverticulopexy.

Methods.
This is an observational descriptive study. Only patients with proven
Zenker’s diverticulum who underwent cricopharyngeal myotomy and
diverticulopexy were included in the study. Patients with recurrences
were included.

Results.
Fifty-four cases were included; subject age ranged from 30 to 89 years
with no sex predominance. Mean follow-up was 6 months. The main
complaint was dysphagia and regurgitation. All patients improved with a
cricopharyngomyotomy and diverticulopexy. There were 4 major
complications and 1 recurrence.

Conclusion.
Cricopharyngomyotomy and diverticulopexy for Zenker’s
diverticulum is a safe procedure for all patients, with very good
outcome and long-term results.

Case presentation. A
68-year-old male presented with a 1-year history of steatorrhoea,
weight loss and a 2-week history of jaundice with pruritus. The patient
had no history of alcohol consumption. Clinical examination revealed
jaundice and a firm 3 cm hepatomegaly. Biochemical testing showed
cholestasis. An ultrasound demonstrated prominent intrahepatic ducts
and dilated common bile duct; however, no obstructing lesion could be
visualised. A magnetic resonance cholangiopancreatogram (MRCP) showed
multiple strictures involving the intrahepatic ducts. Primary
sclerosing cholangitis (PSC) was the most likely consideration.
Colonoscopy was normal. Endoscopic ultrasound (EUS) revealed a
thickened common bile duct wall of 3.3 mm. Fine-needle aspiration of an
indistinct hypoechoic pancreatic head mass showed lymphocytes with no
evidence of malignancy. The IgG4 subset was elevated to 10 times the
upper limit of normal. A diagnosis of IgG4 sclerosing cholangiopathy
was made and the patient was commenced on prednisone therapy. There was
remarkable improvement in the liver function tests and pruritus after 2
weeks of steroids. Repeat endoscopic ultrasound showed reduction in
common bile duct wall thickness to 2.0 mm.

Conclusion.
IgG4-associated sclerosing cholangiopathy should be considered in
suspected PSC as it responds well to steroids. The use of EUS to
evaluate bile duct wall thickness and for subsequent monitoring of
therapeutic response is not well described and may be of value.

Geographic distribution of
gastroscopy referrals to a tertiary unit: Implications for the
development of an equitable endoscopy service

A Rajula, S R Thomson, G Watermeyer

Groote Schuur Hospital and the University of Cape Town

Background.
Gastroscopy is not yet a tertiary hospital procedure. Groote Schuur
Hospital (GSH) provides 80% of the gastroscopy service for the Cape
Metro West Health Area (CMWHA), with the remainder provided by Somerset
Hospital (SH), G F Jooste Hospital (GFJH), and Victoria Hospital (VH).
To plan a comprehensive equitable gastroscopy service, the geographical
distribution of referrals needs to be mapped.

Methods.
From 1 September to 31 October all gastroscopy records entered into a
prospective database at the gastrointestinal unit of GSH added home
location to the dataset. Locations were allocated according to the
catchment areas/proximity of the 4 CMWHA hospitals – and whether
patients’ home locations fell within the catchment areas or not.

Results.
Gastroscopies performed annually included 6 300 at GSH, 1 439
at VH, 1 141 at SH and 0 at GFJH. Of the 482 endoscopies performed
during the 2-month study period, 80 had no recorded address. Sixteen
per cent of the patients were not from CMWHA, while 49%, 10% and 3%
should have gone to GFJH, VH and SH, respectively. Only 22% of the
patients were located within GSH’s true catchment area.

Conclusion.
The gross inadequacy of a secondary-level gastroscopy service is
highlighted. There is an urgent need to establish an endoscopy service
at GFJH and to ensure that the services in the adjacent districts are
responsible for their own patients.

Background.
The efficacy of revisional surgery in failed laparoscopic Nissen
fundoplications (LNFs) (failed due to recurrent reflux and/or new
symptoms following a successful period of antireflux surgery) is
promising in current literature. This is an audit of our practice.

Methods.
Nine cases of revision of failed LNFs were carried out over a 3-year
period at a private surgical practice and analysed by retrospective
chart review. Two cases were failed redo LNFs.

Diarrhoea in Schnitzler syndrome

W Simmonds, O C Buchel, R C Flooks, V J Louw

Universitas Hospital and Department of Health, Bloemfontein, Free State

Background. Schnitzler syndrome is a
rare idiopathic condition characterised by recurrent episodes of
non-pruritic urticarial rash, fever, bone pain, arthralgia or
arthritis, and a monoclonal gammopathy (IgM or more rarely, IgG) in
concentrations <10 g/l. According to the literature, approximately
100 cases of Schnitzler syndrome have been reported to date.

Case description. We report a case of
Schnitzler syndrome affecting a 54-year-old male who, in addition, had
diarrhoea with his episodes of urticaria. No other cause for diarrhoea
was found on further evaluation. We postulate that the diarrhoea may be
caused by excess interleukin-1 activity, thought to be a primary
mediator in Schnitzler syndrome. Ciprofloxacin and loratadine therapy
was initiated in the patient, with good effect.

Conclusion. Diarrhoea in Schnitzler
syndrome has not previously been documented. The probable role of
interleukin-1 as the cause for the diarrhoea requires confirmation.

Gastrointestinal Unit, Groote Schuur Hospital and the University of Cape Town

Background. High-resolution oesophageal pressure topography (HROPT)
details pressure topography of the oesophagus, and an integrated
relaxation pressure (IRP) for the lower oesophageal sphincter complex
which allows subtyping. This study describes the 3 achalasia subtypes
in our patient population and the early outcome of different therapies.

Results.
Eighteen patients had primary achalasia. Average age was 42 years
(range 11 - 77). The frequency of the subtypes was as follows: I
– 5; II – 12; III – 1. The mean lower oesophageal
sphincter pressure (LOSP) of 37 mmHg was highest in subtype II. Female
patients were 3 times more common in type II. IRP increased from
subtype I to III. Nine patients had pneumatic balloon dilatation (PBD),
4 had a Hellers myotomy, and 1 is awaiting surgery. Four patients were
treated elsewhere. Eight have had a good initial result. Two patients
had a repeat PBD. Two patients have not yet been evaluated
post-operatively. One patient has not returned for clinical assessment,
and 1 patient died from a PBD perforation.

Conclusion.
Our early experience with HROTP clearly identifies subsets of patients
with achalasia, which are indistinguishable on standard clinical and
investigational grounds. There is a predominance of subtype II. Greater
accrual and long-term follow-up are required to evaluate if these
subtypes predict durable outcome.